Advanced med surg 2 Flashcards
The nurse administering albuterol (Proventil) via a metered-dose inhaler (MDI)
to a client who has a history of coronary artery disease is now in congestive heart
failure. What side effects will be particularly important to observe for when the client
takes the medication?
a.Tremors and central nervous system stimulation
b. Tachycardia and chest discomfort
c. Development of oral candidiasis
d. An increase in blood pressure
a. Decreased breath sounds are heard over the left side of the chest.
What is the desired action of dopamine (Intropin) when administered in the
treatment of shock?
a.It increases myocardial contractility
b. It is associated with fewer severe allergic reactions
c. It causes rapid vasodilation of the vascular bed
d. It supports renal perfusion by dilation of the renal arteries
a.It increases myocardial contractility
The nurse is monitoring an IV infusion of sodium nitroprusside (Nirpride). Fifteen
minutes after the infusion is started, the client’s BP goes from 190/120 mm Hg to
120/90 mm Hg. What is the priority nursing action?
a. Recheck the BP and call the doctor
b. Decrease the infusion rate and recheck the blood pressure in 5
minutes
c. Stop the medication and keep the IV open with D5W.
d. Assess the client’s tolerance of the current level of BP
b. Decrease the infusion rate and recheck the blood pressure in 5
minutes
Norepinephrine (Levophed) has been ordered for a client in hypovolemic shock.
Before administering the drug, the nurse should make sure that the client has:
a. A heart rate of less than 120 beats/min
b. Urine output of at least 30 mL/hr.
c. Received adequate anticoagulation
d. Been receiving adequate IV fluid replacement
d. Been receiving adequate IV fluid replacement
The client returns to his room after a thoracotomy. What will the nursing
assessment reveal if hypovolemia from excessive blood loss is present?
a. CVP of 3 cm H20 and urine output of 20 mL/hr
b. Jugular vein distention with the head elevated 45 degrees
c. Chest tube drainage of 50 mL/hr in the first 2 hours
d. Persistent increased BP and increased pulse pressure
a. CVP of 3 cm H20 and urine output of 20 mL/hr
The nurse is performing an assessment and finds the client has cold, clammy
skin, pulse of 130 beats/min and weak, blood pressure of 84/56 mm Hg, and
urinary of 20 mL for the past hour. The nurse would interpret these findings as
suggestive of which pathophysiology?
a. Reduction of circulation to the coronary arteries, this increasing the
preload
b. Decreased glomeruli filtration rate, resulting in volume overload
c. Stimulation of the sympathetic nervous system, causing severe
vasoconstriction
d. Decrease in the cardiac output and inadequate tissue perfusion
d. Decrease in the cardiac output and inadequate tissue perfusion
The nurse applies a Nitro-Dur patch on a client who has undergone cardiac
surgery. What nursing observation indicates that a Nitro-Dur patch is achieving
the desired effect?
a. Chest pain is completely relieved
b. Client performs activities of daily living without chest pain
c. Pain is controlled with frequent changes of patch
d. Client tolerates increased activity without pain
b. Client performs activities of daily living without chest pain
The V/S of a client with Cardiac disease are as follows: BP 102/76 mm/hg, Pulse
52, RR 16. Atropine is administered IV push. What nursing assessment indicates a
therapeutic response to the medication?
A. Pulse rate has increased to 70 beats/min
B. systolic BP has increased by 20
C. pupils are dilated
D. oral secretions have decreased
A. Pulse rate has increased to 70 beats/min
An older adult client comes into ER stating that he has no appetite, is nauseated,
his heart feels funny and has noticed a haziness in his vision. The client states that he
has been taking an antihypertensive drug and digitalis for more than a year.
Based on the presenting symptoms, what would be the priority nursing action?
A. Obtain an order for an EKG and serum potassium and digitalis levels
B. Perform a neurological assessment to determine whether he has one side
weakness.
C. Assess lungs for decreased breath sounds and/or adventitious breath
sounds.
d. Obtain an order for an EKG
A. Obtain an order for an EKG and serum potassium and digitalis levels
the nurse is administering alteplase to a client who has been diagnosed with
acute coronary syndrome. What are important nursing implications for this
medication?
A. Monitor the ECG for dysrthymias
B. Place the client on bleeding precautions
C. monitor urine output hourly
D. Monitor for activity tolerance
B. Place the client on bleeding precautions
The nurse is caring for a client who underwent cardiac catheterization 1 hour
ago. What is an important nursing measure at this time?
A. Measure urinary output hourly and maintain continuous cardiac monitoring
B. Encourage client to perform slow pressure exercise of the affected side to
promote circulation.
C. Maintain pressure over catheter insertion site and determine distal
circulation status.
D. Evaluate apical pulse and determine presence of pulse deficit.
C. Maintain pressure over catheter insertion site and determine distal circulation status.
The nurse in a cardiac stepdown unit has received a hand-off shift report for
these clients. Which client should be assess first?
A. a client who has just returned from a coronary artierogram with placement
of an intracoronary stent.
B. A client who is in heart failure and has gained 2 pnds in the last 24 hours.
C. a client with endocarditis who has temperature elevation of 100F and P 100
beats/min
D. A client who was cardioverted from atrial fib 24 hours ago and has had 3 atrial
premature
A. a client who has just returned from a coronary arteriogram with placement of an intracoronary stent.
What ECG changes would reflect myocardial ischemia in a client who has been
admitted for observation after experiencing an episode of chest pain?
A. Prolonged PR interval
B. Wide QRS complex
C. ST- Segment elevation or depression
D. Tall, peak T-waves
C. ST- Segment elevation or depression
A new employee at a facility needs a hepatitis vaccine. Which statement reflects
accurate understanding of the immunization?
A. I need to get 6 shots of hep C
B. Once I receive the Hep vaccine I will always been immune
C. I will receive 3 injections over a period of months, which should protect me
from hep B
D. Hep vaccine is an oral vaccine with live attenuated Virus
C. I will receive 3 injections over a period of months, which should protect me
from hep B
While talking with a client with a diagnosis of end stage liver disease. The nurse
notices the client is unable to stay awake and seems to fall asleep in the middle of a sentence. The nurse recognizes these symptoms to be indicative of what condition?
A. Hyperglycemia
B. Increased Bile production
C. Increased blood ammonia levels
D. Hypocalcemia
C. Increased blood ammonia levels
